- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,400.00 / $1,799.25 / $2,790.06
| Facility | | $1,400.00 | $1,799.25 | $2,790.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,761.74 / $1,881.66 / $2,753.45
| Professional | | $1,761.74 | $1,881.66 | $2,753.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,925.62 / $2,160.69 / $2,354.12
| Facility | | $1,925.62 | $2,160.69 | $2,354.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.58 / $2,092.55 / $2,092.55
| Professional | | $1,073.58 | $2,092.55 | $2,092.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,057.66 / $2,057.66 / $2,057.66
| Facility | | $2,057.66 | $2,057.66 | $2,057.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,752.76 / $2,764.28 / $5,270.82
| Professional | | $1,752.76 | $2,764.28 | $5,270.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,477.30 / $2,441.31 / $3,960.41
| Professional | | $1,477.30 | $2,441.31 | $3,960.41 |